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PaperclipPerfector  27d ago (text post)   24453 thread views

Culture War Roundup for the week of April 8, 2024

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Well, the final report of the Cass Review just dropped. It's getting coverage in mainstream publications like the BBC. Surprising no one who paid attention to the interim report, it concludes that there is insufficient evidence in the realm of trans healthcare for children:

Cass told BBC Radio 4's Today programme that clinicians had been worried about having "no guidance, no evidence, no training".

She said "we don't have good evidence" that puberty blockers are safe to use to "arrest puberty", adding that what started out as a clinical trial had been expanded to a wider group of young people before the results of that trial were available.

"It is unusual for us to give a potentially life-changing treatment to young people and not know what happens to them in adulthood, and that's been a particular problem that we haven't had the follow-up into adulthood to know what the results of this are," she said.

Critics are already jumping on the fact that the report used the GRADE approach to categorize evidence, which only allows randomized control studies to be classified as "high quality of evidence" and which can drop non-blinded studies one level in assessed quality, thus preventing many non-blinded studies from qualifying as high quality evidence. (Bold is edit added later. See ArjinFerman's response below, and my response - original GRADE standards can be found here.) The critics point out that double-blinded randomized control studies just aren't possible in some areas of medicine. For a simple example, if the intervention is something like "cosmetic breast augmentation", then there's logically no sensible control group - since there's no placebo that can make people believe they got bigger breasts when they didn't. (It's worth pointing out that this criticism of GRADE isn't unique to trans activists. The Wikipedia page for GRADE mentions it is criticized in general when it comes to slowly progressing diseases like atherosclerosis, where observational studies are easier to perform than RCTs.)

As a result of the GRADE approach, we read things like this in the report:

Understanding intended benefits and risks of puberty blockers

[...]

There was one high quality study, 25 moderate quality studies and 24 low quality studies. The low quality studies were excluded from the synthesis of results.

My own opinion is that I can partially agree with Cass that I want to see higher quality studies around trans healthcare for children in general, but I think that her methodology (using GRADE) is of the sort that will always say we "don't have enough high quality studies", and so her arguments don't have legs to stand on. A problem I see a lot in studies is using some "industry standard" for investigating a topic, and coming to a result of some kind, but failing to justify why the "industry standard" was the best thing to use here. In a better version of the Cass Review, I would have liked to see a few paragraphs justifying the use of GRADE, and explaining why they used this standard and not some other standard.

I mean, isn't that a thing good scientific reports in general do at all steps of the process? Think of what a critic would claim about your model and methodology, and then explain why your model or methodology is the best one to use in this particular instance. Show that your findings are robust even if you used some slightly different model or methodology, and explain what conditions are necessary for your model or methodology to fail. A quick search through the Cass Review shows that it doesn't seem to have done this. It just used GRADE, didn't really justify the decision, and didn't discuss alternatives or why its arguments are robust under alternative assumptions about the data.

It's a bit circular to arbitrarily use a standard that will say, "there are basically no high quality studies in this medical field" no matter what, and then to conclude in your recommendations to the government, "We need more high quality studies before we do anything more in this medical field!"

The critics point out that randomized control studies just aren't possible in some areas of medicine.

And the critics are wrong. If you give a treatment to one group, and not give it to another to another, that's still an RCT. Or you can offer an alternative treatment to the control group. It's a plus when you can blind a patient to what they're getting, but it's not a strict necessity. In this case it's probably just as important to blind the researchers when they're assessing results as to blind the patients themselves.

In a better version of the Cass Review, I would have liked to see a few paragraphs justifying the use of GRADE, and explaining why they used this standard and not some other standard.

That demand seems arbitrary to me, and "that's what we use for everything" is a perfectly fine justification.

It's a bit circular to arbitrarily use a standard that will say, "there are basically no high quality studies in this medical field" no matter what, and then to conclude in your recommendations to the government.

Where did you get the idea that the decision was arbitrary? That studies with a control group are better than studies without one, or that random samples are better than self-selected surveys, isn't something that Cass ceme up with on the spot. The critics are more than happy to use the same strict standards when dismissing studies they don't like (see: ROGD).

This is all without going into the juicy details about some of these studies, some of which are hilariously bad. The "Dutch study" that kicked off the whole puberty blockers thing would most likely get the same result, even if you replaced blockers with farting in the patient's face, for example.

My opinion is that trans activists and researchers wildly oversold the scientific basis for the interventions they were promoting, and sometimes they were outright lying ("puberty blockers are reversible"). They could have just not done that, and tried to gradually accumulate stronger evidence. But the way things are, gender medicine should have never seen such widespread adoption, and people who allowed it should probably be punished.

And the critics are wrong. If you give a treatment to one group, and not give it to another to another, that's still an RCT. Or you can offer an alternative treatment to the control group. It's a plus when you can blind a patient to what they're getting, but it's not a strict necessity. In this case it's probably just as important to blind the researchers when they're assessing results as to blind the patients themselves.

You're right of course. I think the concerns are more nuanced in some areas of medicine.

I doubt it applies to trans medicine, but I have heard of cases where medicine has such obvious positive effects for the sample group early on, that it then becomes unconscionable to not provide it to the control group (mostly in cases involving terminal diseases with quick turn arounds.) This would be one instance where a study initially meant to be a RCT trial for a terminal disease, might turn into an observational study instead.

And I was clearly thinking of double-blinded RCTs being nearly impossible in some cases, which I believe is true in some areas of medicine, but I can admit that GRADE only requires RCTs period for evidence to be considered high quality. That said, reading through the actual GRADE hand book it does seem like Lack of Blinding is considered a risk for study bias, which can drop a piece of evidence one level:

Example 3: High Risk of Bias due to lack of blinding (Downgraded by One Level)

RCTs of the effects of Intervention A on acute spinal injury measured both all-cause mortality and, based on a detailed physical examination, motor function. The outcome assessors were not blinded for any outcomes. Blinding of outcome assessors is less important for the assessment of all-cause mortality, but crucial for motor function. The quality of the evidence for the mortality outcome may not be downgraded. However, the quality may be downgraded for the motor function outcome.

I'm going to edit my original post to reflect this information, but I'll make clear what I'm adding. Basically, it appears to be the case that non-double-blinded RCTs cannot easily be high quality evidence according to GRADE.

Where did you get the idea that the decision was arbitrary?

I tried to search through the report, and they just used GRADE without really explaining why. I suppose "arbitrary" isn't quite the right word, but "unjustified within the report" is probably defensible.

And I was clearly thinking of double-blinded RCTs being nearly impossible in some cases

Ok, but what does that have to do with the Cass Review then?

I haven't even started reading the report yet, but I looked up the excerpt you quoted about only one study on puberty blockers being high quality. If you check the report, the excerpt references "Taylor et al: Puberty suppression", CTRL+Fing for that takes you to table 1 on page 53. The full title of the systematic review is Interventions to suppress puberty in adolescents experiencing gender dysphoria or incongruence: a systematic review, and the "one study" is Psychological Functioning in Transgender Adolescents Before and After Gender-Affirmative Care Compared With Cisgender General Population Peers. The "methods" section from the abstract says:

Methods: In this cross-sectional study, emotional and behavioral problems were assessed by the Youth Self-Report in a sample of 272 adolescents referred to a specialized gender identity clinic who did not yet receive any affirmative medical treatment and compared with 178 transgender adolescents receiving affirmative care consisting of puberty suppression and compared with 651 Dutch high school cisgender adolescents from the general population.

You can even look up the break down of it's score in the supplemental material of the systematic review (it's the last entry in the table - "van der Miesen"), it only got dinged for "controls for co-interventions" and "assessment of outcome", and still got a final grade of "high quality".

So where is this idea that Cass was autistically demanding a double-blinded study, where it was not applicable, coming from?

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